In a recent perspective article at the Journal of General Internal Medicine, Patrick O’Mahen and Laura Petersen lay out the current status of Medicaid Expansion and how they have slight expectations that the American Rescue Plan financing enhancements will do much to change the situation.
In March 2021, President Joseph Biden signed into law the American Rescue Plan Act (ARPA), providing $1.9 trillion to combat the COVID-19 pandemic. ARPA broadens numerous Affordable Care Act (ACA) policies extending health insurance to the uninsured.1 These reforms include generous financial incentives for states to accept the ACA’s Medicaid expansion. However, because the primary opposition to Medicaid expansion in holdout states is ideological and not economic, the effectiveness of these incentives in coaxing more states to expand is likely to be limited.
Under current law, states that had not expanded Medicaid by the day that the ARP was signed are eligible for the regular 90% federal match for the expansion population plus a bonus 5% match on all Legacy Medicaid expenditures for two years if the state expands Medicaid. This makes Medicaid Expansion a state budget profit center for two years, or half a governor’s term and at least one electoral cycle for the state legislature. Once the two years are up, the state would get the regular 90% match for the expansion population and the standard federal match for Legacy Medicaid. On net, expanding Medicaid under regular conditions is a break even proposition as the states are often able to move people that are covered with state dollars to the enhanced federal program.
The ARP treats Medicaid expansion resistance as a matter of the hold-out states not having the means to expand. When a problem is one that is just a “means” problem, accessing external resources to acquire those additional means will solve that problem.
However, O’Mahen and Petersen are building on the political science literature that shows the resistance is ideological. Rocco and Haeder (2018) argue that intense policy demanders on the right have made Republican elites indifferent, at best, to Medicaid Expansion in the hold-out states. Institutional features such as laws that prohibit governors from expanding Medicaid via executive action as in North Carolina where the Democratic governor wants to expand Medicaid lock in these preferences that likely have majority public support. These views on the role of the public purse and its interaction with individuals in need is not just limited to Medicaid Expansion. We saw this recently in Wisconsin where a school board refused to accept federally funded lunch for all students is a crude example of this ideological opposition to programs that cost the governing body that can accept or reject the program nothing:
A school district opted out of free and reduced-price meals, saying students could “become spoiled” https://t.co/sKOVLjdvkc
— The Washington Post (@washingtonpost) August 27, 2021
The school board reversed itself after it was nationally mocked.
But in the context when it is just a matter of enhancing means versus entrenched mores, the mores, especially when reinforced with status-quo enabling institutional design, will almost always win in a direct confrontation. O’Mahen and Petersen argue that Medicaid Expansion in these hold-out states will only win by non-direct confrontations in the legislatures and governors’ officers. Instead, direct democracy through referendums and a likely federal parallel system will be more fruitful systems of change.
Bill K
I live in Waukesha – the county that turned down school lunches. There was an election recently in this conservative county, and several incumbents on the school board got turned out over the issues of masks and remote learning. Basically the newcomers screamed about “parents’ rights” and the election was only attended by the die-hards. Nobody really followed the logic to “parents have the right to starve their kids”. I think with the national attention these fanatics will get turned out in the next election. Now if only this level of attention could be focused on the damage being done to the medical systems in the entrenched states.
satby
Mockery works. The RW prides itself on being smarter than the “sheeple”. When they’re almost universally reviled as stupid they usually double down on combatitive words while quietly backing off on enforcing their stupid actions hoping their brainwashed followers never notice.
Another Scott
Thanks for this, haven’t clicked the links.
Dunno. You’ve shown us examples over the years of states passing direct referenda for ACA expansion (or giving former felons the vote) and the RWNJs on the legislatures say “NO, you can’t make me!!1”.
There is no One Weird Trick. There are no shortcuts. We have to do the work in the trenches, every election, for every seat, to vote the monsters out and elect sensible people. Politics is important – it’s how we address communal problems. We only make progress by having sensible people in positions of authority.
Thanks again.
Cheers,
Scott.
RaflW
I wonder what the data is on the population of expansion-eligible people in the fuck-you states? What percent is white, and quite possibly working class but down-on-their-luck Trumpy?
So many people screw themselves in service to supporting white supremacy. I’ll die broke from a treatable disease if that black family also doesn’t get gubmit care!
Barbara
I read an article in the NYT this morning about the slow death of rural NC communities in the flood plain, as a result of Hurricanes Florence, and then Matthew. The article was really focused on how existing programs sometimes are at cross purposes over whether the correct response is to buy out homeowners (to give them some economic relief given the devaluation of their house should they try to sell) versus devoting dollars for rebound or rebuilding. However, like David’s post on the moral case maintained by hold out states for letting poor people beg for medical care or just die, it reinforced for me the depressing reality that we are fighting the same old battles drawn with the same lines when we are confronted by an entirely new battle. Is it okay for me to say that I no longer care what happens to these places? I started to feel that way as I read about the horrifying conditions in the hard hit regions of Louisiana. We can’t be in this “all together” only when you specifically need my help.
Suzanne
@satby:
Absolutely right.
They are terrified of being proven dumb. They hate that we’re smarter.
They should “leave the thinking to the sentient”.
Kelly
It is a means problem because the Mean Tribe is in charge. Cruelty is the point.
lige
@Bill K: My brothers school board was just taken over by similar RW activists. It’s a real problem with how low cost and under the radar school board elections can be – it’s easy for these types to at least temporarily capture a board.
Fake Irishman
@Another Scott:
You’re right that there’s no magic trick and that’s exactly what O’Mahen and Petersen argue in the article. The piece looks at a menu of options that are available and discusses the circumstances under which they might work.
To take referenda and direct democracy, for example there are only four states in the holdout group of 12 left (Florida, Mississippi, Wyoming and South Dakota) with provisions to expand Medicaid vis direct popular vote. So it won’t work in Texas or Alabama or Tennessee, but it can still help.
You’re also right that many of those state legislatures and governors in states that have passed expansion via referendum have effed around with it, delayed it and tried to limit it. (Phil Singer has a great piece on this in a 2019 issue of the Journal of general internal medicine). However, in all those states, the expansion has ended up going forward as envisioned.
Gretchen
@Fake Irishman: Missouri passed a referendum to expand Medicaid. The legislature just said Nuh-uh you can’t make us. The Democratic governor of KS has been trying to pass it, and the leg resists even though the rural hospitals keep going under and closing.
Fake Irishman
@Another Scott: To be clear, being familiar with the article, I suspect the authors would strongly agree with your characterization of the political process, but they would also argue some avenues are more likely to work than others in a given state.
Fake Irishman
@Gretchen:
And then the Missouri courts told the governor and legislature to go sit in the corner until they expanded.
Kansas is one of those states that a federal option may be necessary for. It has come tantalizing, agonizingly close to expanding twice in 2017 and 2020. If you click on the “institutional features” link, it goes to an article that discusses Kansas (and Missouri) among others as cases for why institutions matter in Medicaid expansion. In 2013, the state passed a law saying the governor couldn’t issue an executive order to expand, with the exact scenario of a Democrat becoming governor in mind.
(Why yes, I’m a bit of a health policy nerd, why do you ask?)
billcinsd
In South Dakota someone was out collecting signatures to have a referendum on expanding Medicaid in the 2022 election. I hope they succeed.
Ol'Froth
After I retired from policing, I took a job in my local high school’s cafeteria (I love cooking). It doesn’t pay well, but its fun and I really like my coworkers and the kids. We participate in the free and reduced lunch program, and the seamless summer option, which means ALL the meals we serve this year are FREE. I also know parents who refuse to let their kids consume our free breakfast and lunches, because of FREEDOM! or some other such nonsense.